预付制背景下疾病分类编码缺陷及专业性调查与质控探究  

Disease Classification Coding Defects and Professional Investigation and Quality Control Under the Background of Prepaid System

作　　者：陈济兰 方敏 钟立志 CHEN Ji-lan;FANG Min;ZHONG Li-zhi(Medical Record Room of the Second People's Hospital of Yudu County,Yudu 342323,Jiangxi,China)

机构地区：[1]于都县第二人民医院病案室,江西于都342323

出　　处：《医学信息》2023年第7期22-26,共5页Journal of Medical Information

基　　金：赣州市卫生健康委员会市级科研计划项目(编号:2022-2-210)。

摘　　要：目的对预付制背景下疾病分类编码缺陷及专业性进行调查及质控地研究。方法2020年1月-2022年5月随机抽取我院病案首页资料900份为调查对象,分析疾病分类编码缺陷影响因素。同时随机抽取20名ICD编码人员为研究对象,采用自行设计的《编码人员专业性调查问卷》进行问卷调查,了解编码人员的专业性现状,并针对性提出质控措施。结果900份病案中有82份存在编码缺陷,疾病分类编码缺陷发生率为9.11%,其中门诊诊断编码23.17%,主要诊断占比21.95%、次要诊断占比17.07%,主要手术占比14.63%、次要手术占比12.12%,损伤、中毒外部原因占比7.31%,病理诊断占比3.66%;不同住院时间、诊断条数、手术操作条数、科室患者疾病分类编码缺陷发生率比较,差异有统计学意义(P<0.05);不同性别、年龄患者疾病分类编码缺陷发生率比较,差异无统计学意义(P>0.05);多因素Logistic回归分析,住院时间、疾病诊断条数、手术操作条数是病案编码缺陷独立危险因素(P<0.05);不同性别、工作年限、学历、专业、进修经历、是否参加过病案首页或ICD编码的相关培训、是否获得ICD编码技能认证书编码人员所占比例存在差异(P<0.05),不同年龄、是否同时兼任其他工作、是否主动参加病案首页及ICD编码的相关培训人员占比比较,差异无统计学意义(P>0.05)。结论在预付制背景下我院疾病分类编码仍然存在缺陷,且受多方面因素的影响,临床应针对性提出质控措施,以提高编码质量,降低编码缺陷。同时ICD编码人员专业性欠缺,应加强编码人员专业知识和相关培训,以期为预付制背景下疾病分类编码质量的提高做出贡献。Objective To investigate and study the defects and professionalism of disease classification and coding under the background of prepaid system.Methods From January 2020 to May 2022,900 copies of the first page of medical records in our hospital were randomly selected as the survey objects to analyze the influencing factors of disease classification coding defects.At the same time,20 ICD coders were randomly selected as the research object,and a self-designed“coder professional questionnaire“was used to conduct a questionnaire survey to understand the professional status of the coders and propose quality control measures.Results Among 900 medical records,82 had coding defects,and the incidence of disease classification coding defects was 9.11%.Among them,the outpatient diagnosis coding accounted for 23.17%,the main diagnosis accounted for 21.95%,the secondary diagnosis accounted for 17.07%,the main operation accounted for 14.63%,the secondary operation accounted for 12.12%,the external causes of injury and poisoning accounted for 7.31%,and the pathological diagnosis accounted for 3.66%.There were statistically significant differences in the incidence of disease classification coding defects among patients with different hospitalization time,number of diagnoses,number of surgical operations,and department(P<0.05).There was no significant difference in the incidence of disease classification coding defects between different genders and ages(P>0.05).Multivariate Logistic regression analysis showed that hospitalization time,number of disease diagnoses and number of surgical operations were independent risk factors for medical record coding defects(P<0.05).There were differences in the proportion of coders with different genders,working years,educational background,profession,further education experience,whether they had participated in the relevant training of the first page of medical records or ICD coding,and whether they had obtained the ICD coding skill certification(P<0.05).There was no significant difference

关 键 词：预付制 疾病分类编码 编码缺陷 质控措施 

分 类 号：R197.3[医药卫生—卫生事业管理]